Celiac Dx Flashcards
How to treat Celiac dx
dietary counseling with dietician,
monitor lifelong adherence to gluten free diet
access to an advocacy group
what are celiac pts at risk for?
mineral deficiencies, and osteopenia and osteporosis
and peuropsychiatric illness( peirpheral neuropathy, headache, depression) and skin disorders
What kind of nutritional deficiencies can pts with celiac dx suffer from?
iron, calcium, vitamin D, folic acid and rarely thiamine
when to screen for osteopenia and osteoporosis in a celiac pt?
obtain DEXA at diagnosis
repeat DEXA 1 year later if osteopenia is present
have increased bone loss due to vitamin D deficiency
What vaccination to give celiac pt?
pneumococcal vaccination because Celiac pts tend to have hyposplenism
How to treat dermatitis herpetiformis?
dapsone in addition to gluten free diet
Presentation of celiac pt
young person with weight loss and diarrhea and may have skin rash that looks like herpes
complications of celiac disease
malabsorption of vitamin D, iron deficiency anemia and low urinary calcium excretion.
Can also cause osteoporosis.
relatively common cause of Fe deficiency anemia
Celiac’s dx
what causes persistent bowel syndromes in celiac sprue?
poor dietary compliance/symptom recurrence
refractory sprue
EATL (enteropathy associated T cell lymphoma) and ulcerative jejunoileitis
other coexisting conditions like: lactose intolernace, IBS, pancreatic insufficiency, microscopic colitis and small bowel bacterial bowel overgrowth
what are clinical clues that a pt with celiac sprue may have poor dietary compliance/symptom recurrence?
inadvertent gluten ingestion most common cause
persistent histological abnormalities, high antibody titers and careful dietary history and diagnosis
what are clinical clues that a pt with celiac sprue may have refractory sprue?
Type 1: no initial response to gluten free diet for 12 months
Type 2: initial response to gluten free diet but symptoms return despite dietary adherence
poor prognosis and frequent progression to EATL (enteropathy associated T cell lymphoma) and treatment involves glucocorticoids
what are clinical clues that a pt with celiac sprue may have EATL (enteropathy associated T cell lymphoma) and ulcerative jejunoileitis?
due to aberrant T cell populations
presents with abdominal pain and B symptoms and GI bleeding
often presents with intestinal obstruction and perforation
no response to steroids
3 months of fevers, abdominal pain and melena and diarrhea in a celiac pt who affirms that they are eating a gluten free diet
concerning for intestinal lymphoma or enteropathy associated T cell lymphoma
seen pts who have poor dietary compliance
rare and aggresive lymphoma
Clinical symptoms of enteropathy associated T cell lymphoma
abdominal pain, hepatosplenomegaly, ascites, duodenal masses B symptoms (night sweats, fevers, weight loss) and GI bleeding.
May present with obstruction or perforation
Where is the tumor located in enteropathy associated T cell lymphoma
proximal jejunum and less frequently in stomach, small bowel or colon.
what helps to reduce the incidence of enteropathy associated T cell lymphoma
gluten free diet
enteropathy associated T cell lymphoma is rarely seen in
<33 yrs.
diagnosis of enteropathy associated T cell lymphoma
biopsy of resected tumor
see multiple jejunal ulcers with gut perforation
Has poor prognosis and treatment is combination of other therapy with other aggressive T cell lymphomas.
uncontrolled celiac dx causes:
decreased GI vitamin D absorption and see subsequent vitamin D deficiency
This causes hypocalcemia and secondary hyperparathyroidism that elevates PTH
PTH compensates by decreasing urinary Ca nad increases urinary phosphate excretion and normalizes serum Ca but lower serum phosphate.
what happens with prolonged vitamin D deficiency?
see osteomalacia, and inaccessible calcium stores in bone (unmineralized osteoid) and eventual hypocalcemia.
They can develop pseudofractures, bone pain and deformity
extraintestinal manifestations of celiac dx: general
fatigue and weight loss
extraintestinal manifestations of celiac dx: skin
vitiligo
dermatitis herpetiformis
extraintestinal manifestations of celiac dx: MSK
osteopenia/osteoporosis
osteomalacia
due to low vitamin D absorption and see elevated PTH levels
Can see elevated alkaline phosphatase levels and hypocalcemia and hypophosphatemia (From PTH)
extraintestinal manifestations of celiac dx: hematological
anemia
extraintestinal manifestations of celiac dx: neurological
headache
peripheral neuropathy
extraintestinal manifestations of celiac dx: endocrine
autoimmune thyroiditis (hyper or hypo) DM1
extraintestinal manifestations of celiac dx: psychiatric
depression
psychosis
when to get DEXA scan for someone with celiac dx?
at time of diagnosis
regardless of age or menopause status
how to treat pts who have celiacs dx and possible osteopenia or bone disease?
Need calcium and vitamin D supplementation
need to get DEXA scan at time of diagnosis regardless of age or if post menopausal
gluten free diet does improve bone density slightly
serum IgA tissue transglutaminase antibody (or deamidated gliadin antibody) levels can be used to asses response?
yes. Can see it go to low titers after 3-12 months of gluten free diet.
Some people say to do a repeat EGD to assess response but this is done after 4-6 months of dietary modification
celiac can present with only:
elevated aminotransferases
infertility
arthritis and neurological symptoms
and osteoporosis
iron deficiency anemia and arthritis and infertility and elevated aminotransferases
screen for celiac dx.
pt has signs and symptoms of celiac dx (diarrhea, weight loss) no rash. EGD with biopsy shows villous atrophy and increased intraepithelial lymphocytes in 1st part of duodenum. total IgA and tissue transglutaminase serological testing all show no celiac dx.
what is it?
check medication list.
Olmesartan can mimic refractory celiac dx.
olmesartan medoxomil can cause a sprue like enteropathy and this can develop months to years after starting olmesartan.
can mimic refractory celiac sprue with villous atrophy and increased intraepithelial lymphocytes in first part of duodenum.
see severe weight loss and diarrhea and dehydration needing hospitalization.
drug induced sprue like enteropathy tx
treat by stopping the medication
the symptoms and pathological changes will stop after medications are stopped.
initial screening test for celiac’s
IgA anti tissue transglutaminase
confirmation testing is with IgA antiendomysial antibodies.
if both positive then needs EGD for biopsy of duodenum to confirm villous atrophy to make diagnosis.
what vaccine do you give everyone with celiac’s dx?
pneumoccocal vaccine. they have hyposplenism reported and relatively common.
